Distal penile pyogenic granuloma: A case report

Key Clinical Message The mainstays of treatment for granuloma pyogenicum include careful evaluation of any penile growth, thorough excision of the polypoid, histological examination, and close monitoring to check relapse and management. Abstract Pyogenic granuloma is an acquired noncancerous vascular proliferation that arises from the mucosa and skin, seldom subcutaneously or intravascularly. It is also referred to as telangiectasis granuloma or lobular capillary haemangioma. The risk factors include vascular abnormalities, medicines, hormones, and microtrauma. We discussed the case of a 24‐year‐old man who had a poorly managed ventral distal penile polypoid lesion at a peripheral hospital. Upon further histopathological examination, the diagnosis of pyogenic granuloma was made. Histopathologically speaking, the term “pyogenic granuloma” is misleading because the illness is not linked to the production of granulomas. Pyogenic granuloma's etiopathogenesis is still unknown; true hemangioma is thought to be a reactive hyperproliferative of the vasculature brought on by a variety of stimuli; pyogenic granuloma may be caused by uneven angiogenic factor production in response to minor local trauma or cutaneous disease. Histopathological analysis and surgical excision are the methods used for diagnosis and treatment. The mainstay of treatment for granuloma pyogenic granuloma includes careful evaluation of any penile growth, thorough excision of the polypoid, histological examination, close follow‐up to check for relapse, and early management.


| INTRODUCTION
Pyogenic granuloma is an acquired noncancerous vascular proliferation that arises from the mucosa and skin, seldom subcutaneously or intravascularly.It is also referred to as telangiectasis granuloma or lobular capillary hemangioma.It appears as a painless papule or lump that may bleed with or without minor trauma. 1,2It usually takes the form of a polypoid and can be further classified into subtypes, including eruptive, dermal, intravascular, and subcutaneous.Head skin, oral mucosa, gingiva, trunk, neck, lower and upper extremities, and perianal are the most common places, with the genital areas being the least common. 3Vascular malformation, oral contraceptives, hormonal factors, pregnancy, and skin irritations resulting from trauma, poor hygiene, vasculitis, foreign objects, inflammatory skin conditions, oral retinoid therapy, and the antiretroviral medication indinavir are among the factors that predispose an individual to this condition.5][6][7][8] It is astounding that microdamage during sexual activity is prevalent while genital pyogenic granuloma is uncommon. 9,10We present a case of a 24-year-old male who presented at our facility with distal penile ulcerated polypoidal nodules.

| CASE HISTORY
We discuss the case of a 24-year-old patient who had a ventral distal and glanular penile ulcerative lesion for 6 months and was seen at peripheral clinics.The lesion began as a small lump near the coronal and got worse over time, to the point where it became difficult for the patient to void.However, the patient denied any history of syphilis or relating the insult to sexual intercourse; a venereal disease research laboratory test was negative.The lump was ruptured at the health center, and two unsuccessful attempts to close the wound left the lesion extending to the glans and distal penile.Upon admission, a lobular pattern of vascular proliferation with inflammation and edema resembling granulation tissue was observed along the borders with limited pus discharge, the external urethral meatus at the subcoronal location, and suture materials from the peripheral hospital (Figure 1A).

| METHODS
The patient was kept on antibiotics, excision of the polypoid margins of the wound was done, skin to mucosal approximation was not done, the edges of the urethral plate were allowed to granulate, and a biopsy was taken for histopathological study, which demonstrated dense plasma cell infiltrates which and lobular pattern of vascular proliferation with inflammation and edema resembling granulation tissue of the penile granuloma pyogenicum (Figure 2A,B).When this patient returned after 2 and 6 months, the penile wound had completely healed, as shown in (Figure 1B,C), respectively.However, the patient complained of an annoyingly spreading pee stream; therefore, we advanced the meatus near the tip of the glans of the penis, which was followed by the creation of glanular wings to allow glanuloplasty.(Figure 1D).

| CONCLUSION
Comprehensive examination of any penile growth with a focus on identifying external and local sources of longterm irritants, such as smegma, phimosis, and traumatizing events, avoiding squeezing or rupturing the polypoid lesion, and totally excising the growth, together with histological evaluation coupled with regular close follow-up to detect early recurrence, are the mainstay of treatment for pyogenic granuloma.For our case urethral catheter was removed after 2 weeks post meatal advancement, 3 months later the patient was voiding well with single straight urine stream.

| DISCUSSION
Histopathologically, the acronym "pyogenic granuloma" can be misleading because the condition itself is not linked to the development of granulomas. 3Inakanti Y et al provided a brief overview of the illness's history, beginning in 1844 with Hullihen's report on the first instance of pyogenic granuloma.In 1897, pyogenic granuloma was given the name Botryomycosis hominis; this is attributed to Poncet and Dor, and Hartzel is credited with coining the term "pyogenic granuloma" in the early 1900s. 11yogenic granuloma's etiopathogenesis is still undetermined; true hemangioma is thought to be reactive hyperproliferative of the vasculature brought on by a variety of stimuli; pyogenic granuloma's pathogenesis may involve uneven angiogenic factor production after mild local trauma or cutaneous disease. 12Biopsies are required for penile lesions that grow quickly due to unknown stimuli that cause endothelial proliferation and angiogenesis, present with unusual morphologies, and do not respond to anti-wart treatment. 5,13The table below shows several cases of penile pyogenic granuloma, depicting the location of the lesion in the penis, histology, and treatment given.Clinical differential diagnoses of pyogenic granuloma are pyoderma gangranosum of the penis, urethral caruncle, urethral prolapse, angiokeratoma, genital warts, and cherry angioma. 11reatment options for pedicunculated pyogenic granuloma comprise cryotherapy, cauterization and curettage, or diathermy coagulation of the base.While pulsed dye lasers can be used to manage small lesions, electrodesication is not always the best option as it can cause irreversible changes.Squeezing the lesion is discouraged, and when recurrence occurs, the best course of action is to excise a thin, deep ellipse underneath the lesion; imiquimod and timolol are suggested as effective topical therapies. 5,6,8,10There is a possibility for recurrence irrespective of the method utilized to remove the lesion, particularly if it was not entirely excised or if there are recurring irritations such as phimosis, smegma, or slight trauma. 14here aren't many cases of penile pyogenic granuloma in the literature, and most of them involve children and young adults.Histopathological evaluation and surgical excision are used to diagnose it; prior to excision, an ultrasound scan could show a vasculogenic lesion. 7,9A biopsy must be collected for a histopathological study in order for an expert to properly diagnose this dermatological disorder (Table 1). 14he aforementioned table lists examples of pyogenic granuloma cases that were surgically treated and followed for an average of 6 months.All of these cases did not have a recurrence and had common histological characteristics, including a lobular pattern of vascular proliferation and inflammatory infiltration.

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I G U R E 1 (A) Picture prior excision of the lesion showing eroded ventral part of the glans extending to sub coronal with some necrotic tissues, pus and sutures, exposing the navicularis fossa.(B) Two months post excision with completely healed wound.(C) 6 months postsurgical excision.(D) Post meatoplasty and glanuloplasty.

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I G U R E 2 (A) Hisitopathology of pyogenic granuloma demonstrating a lobular pattern of vascular proliferation with inflammation and edema resembling granulation tissue, H&E staining 200× original magnification.(B) Photomicroscopy of pyogenic granuloma lesion demonstrating dense plasma cell inflammatory infiltrates; H&E staining 400× original magnification.T A B L E 1 Showing location of the lesion in the penis, histology, and treatment given.